HospitalInspections.org

Based on review of records and interview, the hospital failed to ensure informed consent for treatment was obtained from 1 (Patient #3) of 5 patients (Patient #1, #2, #3, #4, and #5) reviewed.

Review of Patient #3's chart revealed she was a 28 year old female who came to the Emergency Department because she was suicidal. The patient had a history of psychiatric illness but was not taking any medication for it. She was prescribed and given Seroquel (a medication classified as a psychotropic medication that requires informed consent prior to administration) on 4/3/2017 at 12:12 A.M. Further review of chart revealed Patient #3 had not signed a medication consent for treatment with this psychotropic medication. A consent for treatment with Seroquel was not obtained until 16 hours later, after the patient had been admitted to the psychiatric unit of the hospital.

Interview with Staff #9 was conducted. Staff #9 stated they do not have patients sign medication consents in the ED for psychotropic medications given for emergency treatment. Further review of the chart with Staff #9 revealed the Seroquel had not been ordered for a psychiatric emergency. Staff #9 stated the ED did not have access to the medication consents for psychotropic medications.

Based on review of records and interview, nursing staff failed to document the reassessment of patient response to pain interventions in one (Patient #2) out of 5 patient charts reviewed (Patient #1, #2, #3, #4, and #5).

Review of Patient #2's record showed that she was a 50 year old female who presented to the Emergency Department (ED) after falling approximately 8 feet down. She was complaining of back pain, shoulder pain, and foot pain. She arrived at the ED at 2:07 P.M. Her initial pain assessment was documented on the Trauma Flowsheet Pain Assessment. She rated her pain a score of 6 out of 10 (where 10 is the worst pain). At 2:37 P.M. it was documented that she was given an ice pack for her back. At 2:40 P.M. it was documented that she was given an ice pack for her shoulder. At 3:33 P.M. it was documented that she received in intramuscular injection (medication injected into a large muscle) of Toradol (a non-narcotic pain reliever). After reviewing the chart, no documentation was found relating to the reassessment of her pain after the specific intervention. The next pain assessment was at discharge at 6:22 P.M. It was noted upon discharge, her pain had decreased to a 2 out of 10.

Interview was conducted with Staff #9. Staff #9 confirmed that the nursing staff are expected to reassess the effectiveness of pain interventions. Staff #9 advised that the nursing staff use Lippincott Procedures for their guidelines.

Review of the Lippincott Procedures provided by the hospital staff, page 2 of 7, was as follows:

"At all levels of health care, the standard for performing a complete pain assessment is: ... when monitoring the effectiveness of pain interventions or treatment modalities"

Staff #9 confirmed that there was no follow-up pain reassessment in the patient chart except upon discharge.

Based on observation, interview and record review the facility failed to;

A. ensure patient information was confidential and stored securely in 1 of 1 Laboratory area (Main campus).

B. ensure unauthorized individuals cannot gain access to patient records in the medical records department.

This deficient practice had the likelihood to cause harm to all patients.


Findings include:




During an observation on 06/20/2017 after 2:00 p.m., cardboard boxes containing patient personal test results was found stored in an unlocked lab storage area. The information included the patient's name, date of birth, medical record number, sexual gender and test results.

Staff #57 confirmed the observation. Staff #57 confirmed there was a staff break room which was attached to the storage area. The restroom which was located in the same area was shared by retail pharmacy staff. Staff #57 reported housekeeping staff also came into the area.



Review of a facility policy named "Storing and Securing PHI" (Protected Health Information) dated 01/2017 revealed the following:

"Departments or clinics that store PHI in any electronic or paper format, including patient records, must maintain the PHI in areas." ...

"When not in use, PHI must always be protected from unauthorized access. When left in an unattended room, such information must be appropriately secured."




32143


A tour of the medical records department was conducted on 6/20/17. The medical records department had recently been moved out of the hospital and located in a warehouse on the hospital grounds. Upon arrival to the warehouse the large roll up door was noticed open to the warehouse. The surveyor walked directly into the warehouse. There was no one noticed in the warehouse area. Looking into the warehouse multiple shelving units were noted to be over 15 feet tall and contained numerous boxes of medical records. At the other end of the warehouse another large roll up door was seen and was closed shut. The warehouse was very hot and had fan units in the walls open to the outside.

An interview was conducted with the HIM Director, staff #20, on 6/20/17. The HIM Director reported the charts are electronic but there are still paper copies of the chart that are scanned in and kept. The Director reported the multitude of records found in the warehouse were charts before the facility went electronic last year. The Director stated the warehouse gets very warm and they have opened both roll up doors in the building to let the air come through when filing or retrieving charts. The Director acknowledged the door was open when the surveyor arrived and stated that the medical records runner had opened the door and drove the golf cart in to deliver charts. The Director did acknowledge there was no one in the warehouse and anyone could have walked in unnoticed and obtained a patient's medical record.

Review of the warehouse revealed there was no fire sprinklers in the building. There was also no fire protection for the medical records in the warehouse. Staff #21, safety officer, confirmed there was no protection from fire or water to the stored patient medical records.

Based on observation and interview the facility failed;

A. to ensure a sanitary environment.

B. ensure the infection control officer was identifying, reporting, investigating, and controlling infections in 5 departments, Central Supply Warehouse, Kitchen, Laboratory, Radiology, or Psychiatric Outpatient areas.

Refer to Tag A0749

Based on observation and interview the facility failed to:

A. ensure a sanitary environment.

B. ensure the infection control officer was identifying, reporting, investigating, and controlling infections in 5 departments, Central Supply Warehouse, Kitchen, Laboratory, Radiology, or Psychiatric Outpatient areas.

This deficient practice had the likelihood to cause harm to all patients.


During an observation of the Kitchen area on 06/20/2017 after 10:30 a.m., the following was found:

1. A three tier metal shelf holding clean pans was found. The bottom shelf had a piece of plastic covering the bottom shelf. The plastic was broken with large pieces missing. The pans were exposed to splatter from the floor during mopping and cleaning.

2. Three Broken tiles in the kitchen were found missing and broken on the baseboard of the wall and on the floor around the floor drain. Heavily soiled grout was found between the tiles on the floor. Pieces of grout were missing between the tiles throughout the kitchen leaving soiled food particles trapped. The floors were not able to be cleaned properly.

3. The large floor mixer in the kitchen was rusted and missing paint on the legs and arms. The mixer was unable to be cleaned properly.

4. In the clean kitchen drying area, a metal rack was found for drying plastic lids for patient plates. The rack was found to be soiled with food particles, dust, and rust.

5. The walk in refrigerator and freezer were filled with shipping boxes. The boxes were not unloaded in the soiled area before placing the soiled and opened shipping boxes in the refrigerated and freezer areas.

6. The wooden door between the hallway and the kitchen was heavily soiled and worn. The door was not painted or sealed and now was porous. The door was unable to be cleaned properly.

7. The floor threshold to the kitchen was soiled and had a buildup of dirt and food particles.

During an observation of the Central Supply Area on 06/21/2017 the following was found:

8. There was no designated clean or dirty area for the shipped supplies and open medical supplies. Open medical supplies were found mixed in with shipping boxes of medical supplies, office supplies, and harsh cleaning supplies.

9. Multiple shipping boxes of patient supplies were found on the floor.

10. Shelving for patient supplies was found covered with plywood. The plywood was unpainted and unsealed. The shelves were porous, dusty, and dirty. The shelves were unable to be cleaned properly.

11. The central supply warehouse had large fly strips hanging down over open medical supplies. The fly strips had numerous bugs on them.

12. The central supply warehouse main door was located on the loading dock. The door to the warehouse was found open and covered with a plastic strip curtain. The door to central supply was found to be approximately 8 feet away from the trash dumpster. There was no solid barrier to prevent bugs or rodents from entering the warehouse.

13. A box of IV start kits and Tracheostomy kits, were found opened next to bleach products and office supplies. The Tracheostomy kits were dusty.

14. Opened plastic bed pans were found sitting on unsealed wooden shelves. The bed pans were dusty and soiled with dirt particles

15. An open box of oxygen tubing was found sitting on a soiled wooden cart with other unopened shipping boxes. The walls and floors surrounding the tubing had dust, dirt and cob webs around it.

16. Open IV fluid warming sets were found sitting on a bottom unsealed wooden shelf. The shelf and supplies were dusty and soiled. The box of supplies were found sitting next to a heavily soiled broom and dust pan.

17. The concrete floor in the central supply warehouse had multiple areas of concrete missing causing large holes. The holes were filled with dirt and debris. The floor was unable to be cleaned properly.

18. The central supply warehouse had metal shelves of medical supplies that have been taken out of their shipping boxes and placed in open plastic bins. The metal shelves and bins were soiled with a heavy dust. A step ladder was sitting next to the supplies. The ladder was heavily soiled with dust, dirt, and hair.

19. In the central supply warehouse an open drain was found with a leaking pipe. Fluid was running out of the pipe and onto the floor then into a drain. The drain and pipe was approximately 2 inches from open patient medical supplies on wire shelves. The drain and pipe had mildew and mold hanging from the pipe. Mildew was found along the back wall. On the other side of the leaking pipe was a pallet of IV fluids in shipping boxes.

20. Soiled wooden pallets were found stacked next to open medical supplies.


During an observation of the outpatient psychiatric day area on 06/21/2017 9:00 a.m., the following was found:

21. The sink and snack preparation area at the outpatient center was missing paint and exposed particle board. The area was unable to be cleaned properly.

An interview was conducted with the Infection Control Director, staff #13, on 6/21/17. Staff #13 reported that she did not have a certification for infection control and had been in this position for eight years. Staff #13 escorted the surveyor to the central supply warehouse. Staff #13 identified the boxes on the floor, no clean or dirty area, the bug strips hanging over the medical supplies and the general dust and debris in the warehouse. Staff #13 reported that she was aware these issues were in the central supply room area and had reported the issues to environmental but nothing had been done. Staff #13 was unable to provide the surveyor with any infection control reporting or rounding for the central supply area.

An interview was conducted with staff #24, Director of Medical Management, during a tour of the central supply warehouse on 6/21/17. Staff #24 reported there was no clean or dirty area designated within the warehouse. Staff #24 reported all supplies for the hospital are brought to this loading dock and brought directly into the central supply area with the medical supplies. Staff #24's attention was brought to the open medical supplies, boxes on the floor, no designated clean area's and dusty, dirty medical supplies. Staff #24 stated, "It's been like this for years! Why is this a problem now?" Staff #24 was unable to voice her understanding of general infection control issues.



10135

Main Laboratory


During an observation of the main laboratory area on 06/20/2017 after 11:30 a.m., the following was found:


Inside the sweat test room were movable tables which contained lab supplies. The edges on the tables had nicks exposing the particle board underneath. There was no way the tables could be properly sanitized in this condition.


Inside the main lab was a shelf which contained shipping boxes, clean supplies used to perform test and a patient urine specimen in an open basin. There was no separation of clean and dirty.


The floor behind the blood refrigerators was soiled with a build-up of dust and spills. The bottom of a file cabinet located in the same area was rusted, had a build-up of brown substance and hair caked up on the floor around it.


Lab equipment which was in use was sitting on cabinets which were soiled with spills and a build-up of dust. Some of the cabinets had areas which were rusted and could not be properly sanitized.


A cell washer was found having areas which had rusted. There was a metal ring mounted into the top of a cabinet, which had plastic tubing going through it. The plastic tubing was connected to the cell washer. The metal casing had completely rusted over.


White test tube holders which had patient specimens stored on them were found soiled with spills and with a black build-up.


Petri dishes and open cotton tip swabs were stored in a drawer with other supplies. Some of the cotton swabs were not contained in anything. The petri dishes contained a 4 x 4 dressing and two wooden sticks. The petri dishes were soiled and some had wooden sticks which had turned from a light brown to black in color.


Clean testing supplies were stored in cluttered cabinets and on shelves which had rusted. There was no protective barrier underneath the supplies.


In the molecular unit of the lab an incubator was found with petri dishes of specimen stored in it. Walls inside the incubator were rusted.


Storage refrigerators in the area were found with a build-up of spills and dead roaches.


A lab supply caddy was found in the same area with a build-up of soiled tape which had turned black and the inside compartments had a build-up of dust.


Inside the vent hood area was a metal container of inoculation loops. The outside of the container had a buildup of brown substance and paper residue. The brown substance could also be seen inside the container.


Lab supplies were stored on metal shelves in the same area. Some of the supplies had been removed from their boxes. There were also shipping boxes stored on the same shelf and above these supplies.


In the histology area was a vent hood that was being used. The glass window at the front of the hood was covered with a white film. There were supplies, basins and metal racks stored underneath the hood. When a plastic basin was lifted there was a build-up of dust that could be seen underneath it. A commercial blender that was being used was found stored underneath the area and it was covered with a build-up of white substance and rust. There was a metal rack stored at the sink and it was covered with rust. The sink was soiled with a build-up of spills. There was an outside lower metal panel on the front of the vent hood and it was soiled with dried brown spills.

During an interview on 06/20/2017 after 2:45 p.m., Staff #59 reported the vent hood was being used and there was no cleaning schedule for it.


Two tissue processors were found in the same area. The front of the equipment was covered with white spills. The floor around the equipment and the wheels on it were soiled.


The research refrigerator in the room was soiled with spills. When the door of the refrigerator was opened the inside bottom panel and floor was soiled.


A storage closet in the area was found to be cluttered. There were clean lab supplies, paper supplies, bottles of testing solutions, empty plastic containers, plastic funnels, dust pans and brooms all stored together. The floor in the closet had a buildup of dirt.


A pegged board was found with beakers and hemostats stored on it. The board was soiled with spills and some of the hemostats were rusted.


Another room was found where tissue analyzer was housed. There were cabinets containing lab supplies stored in them. The outside of the cabinet doors and crevices had a build-up of brown substance. The floor of the cabinet underneath the sink was rusted and there were mice traps placed out.

One cabinet was missing the doors and the floor was missing. The concrete subfloor was exposed. There was a hole at the bottom of the back wall of the cabinet which presented an entry way for pest.



The main supply area contained metal shelves with open supplies stored on them and other clean supplies in shipping containers. Some of the shipping boxes were stored over open supplies.


The walk- in refrigerator contained an abundance of lab supplies which included tissue preparation supplies and solution. Some were stored on the floor and some on rusted metal shelves. The floor in the freezer was soiled with a build-up of spills, paper, dirt and debris. There was also no protective splash guard on the bottom shelves to protect the supplies from contamination.

Staff #54 and 57 confirmed the observations.


According to the Association for the Advancement of Medical Instrumentation (AAMI ST46-Section 5.2 Receiving Items) the following was documented:

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust."




Radiology


During an observation on 06/20/2017 after 2:00 p.m., the ultrasound area was found with the following:

Two vaginal probes were stored inside a wooden drawer and contained inside plastic sleeves.

A trophon vaginal probe sterilizer with a preventative maintenance due date of 02/2017 (over 3.5 months late).



Review of the facility's Trophon "High-level Disinfection Log" forms from January 2017 -June 2017 revealed a category for staff to document the cycle time in and time out, cycle # and pass/fail.

Staff failed to consistently document when a load was started and stopped.


Review of the form revealed "each time when opening a new box of "CHEMICAL INDICATOR", document on next avail row" LOT #, & EXP. DATE."

Staff failed to document when chemical indicators were being opened and the expiration date on the form.

Staff #46 and 47 confirmed the vaginal probes were currently being used that were stored in the drawer. They confirmed the storage area of the vaginal probes and that the preventative maintenance on the equipment had expired. Staff #47 reported that the equipment had been providing a message that it needed a preventative maintenance. Staff #47 confirmed the missing elements from the log and reported she could not tell when the probes were being put in and removed from the sterilizer.



According to CIVCO Medical Solutions (civco.com) article "Store Ultrasound Probes Safely" dated January 17, 2017 the following was documented:

"The Joint Commission issued guidelines on storage for semi-critical devices in 2013:

"Store the device in a manner that will protect from damage or contamination and that is consistent with national guidelines and manufacturers' recommendations such as hanging vertically in a cabinet and storing in a clean environment."

According to the Spaulding Classification , endocavity transducers are semi-critical devices. These transducers include endovaginal, endorectal and transesophageal (TEE) probes.

Here are some key pointers:

DO:

DO SEPARATE CABLES FROM PROBES. Unlike endoscopes, only the probe itself is disinfected. Make sure that the probe's cable and electrical connector do not come in contact with the probe during handling and storage.

DO HANG VERTICALLY. When not in use, hang probes vertically to aid drying and protect the cable.

DO USE HEPA FILTERS. A storage cabinet with a fan and HEPA filtered air provides positive air pressure and facilitates drying.

DON'T:

DON'T PROMOTE MICROBIAL GROWTH. Plastic bags can promote microbial growth - the probe must be completely dry!

DON'T USE THE CASE. The original transducer shipping case should not be used for storage once the probe has been used as it can promote recontamination.

DON'T STORE IN UNSAFE AREAS. Avoid storing in areas where cross-contamination or damage to probe can occur."